Hearing Research 380 (2019) 108e122

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Hearing Research
journal homepage: www.elsevier.com/locate/heares

Review Article

Why and how music can be used to rehabilitate and develop speech
and language skills in hearing-impaired children
Ritva Torppa a, Minna Huotilainen a, b, *
a
Cognitive Brain Research Unit, Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Finland
b
CICERO Learning Network, Faculty of Educational Sciences, P.O.Box 9, 00014, University of Helsinki, Helsinki, Finland

a r t i c l e i n f o a b s t r a c t

Article history: This paper presents evidence for a strong connection between the development of speech and language
Received 24 April 2018 skills and musical activities of children and adolescents with hearing impairment and/or cochlear im-
Received in revised form plants. This conclusion is partially based on findings for typically hearing children and adolescents,
11 June 2019
showing better speech and language skills in children and adolescents with musical training, and
Accepted 14 June 2019
Available online 25 June 2019
importantly, showing increases of speech and language skills in children and adolescents taking part in
musical training. Further, studies of hearing-impaired children show connections between musical skills,
involvement in musical hobbies, and speech and language skills. Even though the field is still lacking
Keywords:
Cochlear implant
large-scale randomised controlled trials on the effects of musical interventions on the speech and lan-
Hearing aid guage skills of children and adolescents with hearing impairments and cochlear implants, the current
Language evidence seems enough to urge speech therapists, music therapists, music teachers, parents, and chil-
Speech dren and adolescents with hearing impairments and/or cochlear implants to start using music for
Music enhancing speech and language skills. For this reason, we give our recommendations on how to use
Child music for language skill enhancement in this group.
Brain © 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
1.1. The tasks of the auditory system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
1.2. Music can enhance auditory processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
2. Musical activities and children with hearing impairments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2.1. Correlational and cross-sectional studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2.2. Intervention studies without a control group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
2.3. Musical interventions with a control group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
3. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4. How to use music to enhance speech and language skills of hearing-impaired children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Declaration of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

1. Introduction
* Corresponding author. Cognitive Brain Research Unit, Department of Psychol-
ogy and Logopedics, Faculty of Medicine, University of Helsinki, Finland. Music has been an integral part of the everyday care of hearing-
E-mail address: minna.huotilainen@helsinki.fi (M. Huotilainen).

https://doi.org/10.1016/j.heares.2019.06.003
0378-5955/© 2019 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
impaired children for centuries (in addition to speech therapy and
other rehabilitation of speech and language skills). This review
examines the scientific foundations of this: we review the reasons
why music could and should be used for improving the speech and
language skills of children with hearing impairments. In addition,
we propose instructions and guidance for the use of music with
children of different ages, varying backgrounds, mild to severe
hearing impairments, with cochlear implants and/or hearing aids,
for speech therapists, music therapists, music educators, parents,
and other members of the child's community.
1.1. The tasks of the auditory system
The human auditory system performs an abundance of tasks.
During human evolution, as hunter-gatherers, a key task of our
auditory system was to serve as a warning system of potential
danger, perhaps the sound of a predator. The warning system must
be very accurate and efficient in detecting danger, while at the same
time the system must allow the full use of our cognitive capabilities.
A hunter-gatherer can be very heavily engaged in a visual task (for
example, searching for and collecting berries in the forest), but also
safe at the same time, since the auditory system pre-consciously
monitors the safety of the environment (Posner, 1980). If any
sound of a potential predator is heard, the auditory system calls for
a switch of attention towards the sound (Na €a
€t€
anen, 1992). The
possibility of placing trust in the auditory system has allowed
humans to develop cognitive skills up to the present high level. This
is a balancing act: if the warning system is too sensitive, cognitive
activities are disturbed too easily and often by irrelevant sounds,
and it is difficult to concentrate (Posner, 1980). On the other hand, if
the warning system is not sensitive enough, there is a risk of danger
when an important sound is unnoticed.
Another important task of the auditory system is communica-
tion. Like most mammals, humans use sounds and gestures in
communicating with others. Researchers propose that some
communicative gestures and sounds evolved into human lan-
guages, while others evolved into music and dance (Mithen et al.,
2006). Both language and music place high requirements on the
auditory system. It has been proposed that by studying the acoustic
characteristics and features of all human languages and musical
genres we can learn about the capabilities of the auditory system -
or, put the other way around - the capacity of the human auditory
system dictates the boundaries of expressive features in language
and music (Patel, 2010). Language and music, even though
constantly changing, would not evolve in directions that require the
use of acoustic features that are too difficult to extract, detect,
compare or remember for the average human auditory system.
Today, our auditory system still has these two key tasks:
monitoring the environment for safety or sounds of interest, and
communicating via language and music. Skills in these tasks are
relevant for children with hearing impairment who are users of
different types of implants and hearing aids.
1.2. Music can enhance auditory processing
Music has very specific acoustic characteristics. Melodies
include fast progressions of notes typically chosen from consistent
scales that typically include uneven steps. Chords are collections of
simultaneously played notes that form harmonies. Musical timbres
are characterised by their spectral peaks and their changes, fast
friction and noise sounds, sound wave envelopes and several other
characteristics, which are highly similar to those that characterise
the important basic elements of speech.
Both speech and music are human universals, found in all hu-
man cultures (Besson et al., 2011; Patel, 2014). Both language and
109
music consist of perceptually discrete elements that are organized
into hierarchically structured, coherent sequences. This organisa-
tion of language and music is not random, but proceeds according
to syntactic principles (Patel, 2003).
The similarities of the syntactic processing of language and
music, as well as the similarities at the acoustic level, have given
rise to models and proposals concerning the effects of music on
speech perception and language capabilities (Patel, 2003, 2011,
2014). In addition to the similarities and the theoretical work, there
is neural evidence that musical activities can affect language skills.
The first evidence for the effects of musical training on brain
structure was provided by the seminal studies of Pantev, Elbert, and
their coworkers (Elbert et al., 1995; Pantev et al., 1998), showing
enlarged motor and somatosensory cortical areas in professional
musicians. These effects were originally interpreted as being
caused by brain plasticity due to musical practice. However, studies
of adult musicians, ranging from observations of structural changes
like enlarged and highly active auditory cortical areas and motor
and somatosensory areas, and enhanced white matter tracts, even
though showing interesting differences between musicians and
non-musicians, fail to assess the causality of such differences.
Theoretically it is possible that individuals with “musician-like”
brain structures determined by genetic factors end up becoming
musicians more often than others. As a result, studies of the effects
of music have moved towards long-term follow-up studies and
interventional paradigms.
Importantly, Hyde et al. (2009) found improvements in auditory
skills and neural structures in 5-6-year-old children after musical
training of 15 months. The structural neural changes were mainly in
the temporal, frontal, and parieto-occipital cortical areas, i.e., the
very same areas in which adult professional musicians show the
largest and most consistent cortical enlargements. In addition,
Dittinger et al. (2017) found that in a task of learning novel words,
children with musical training were faster and had enhanced brain
responses to learnt words. These findings highlight the connection
between musical training and auditory attentional, language and
learning functions in children.
Similarly, Putkinen et al. (2014a,b) studied a group of children
starting musical hobbies at the age of 7 years and a comparable
control group starting other hobbies, and found that brain re-
sponses related to sound perception, discrimination and attention
allocation were initially very similar for the two groups, but two or
more years later, the brain responses had increased in those chil-
dren who started musical hobbies.
Moreno et al. (2011) used an intensive, 20-day intervention with
randomised groups of 4-6-year-old children who played a com-
puter game teaching either music or visual arts for 2 h per day. Only
the musical training improved the verbal intelligence (vocabulary
scores from the Wechsler Preschool and Primary Scale of Intelli-
gence; Wechsler, 2010) of the children and there was a parallel
increase in neural indices of executive functions and auditory
working memory. For the visual training, there was a trend for an
improvement only in spatial skills, which could not be distin-
guished from a practice effect. In two other studies (Janus et al.,
2016; Moreno et al., 2015) a similar intervention of 20 days, 2 h/
day showed improvements in musical skills and music-related
brain responses as well as executive functions in children whose
intervention taught them musical skills. These cognitive aspects are
important for speech perception, language learning and learning in
general. Thus, improvement in cognitive skills with musical activ-
ities is probably one reason for their positive effects for speech
perception and language skills (for a review, Moreno and Bidelman,
2014).
Kraus and Strait (2015) gave children the possibility of attending
musical training for two years, and observed several changes in
110 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
domains of language. First, after two years, the fidelity of the brain
stem response in replicating the acoustic content of a consonant-
vowel syllable had significantly increased. Second, high brain
stem response fidelity and temporal accuracy correlated with bet-
ter reading skills. In a waiting-list design, the children served as
their own controls, enhancing the value of the results.
Tierney et al. (2015) investigated whether musical training
starting in adolescence (without prior musical training in child-
hood) and offered at school can affect the development of the
auditory system and language processing. They found that three
years of in-school musical training accelerated the development of
the N1eP1-response which was used as an index of the maturation
of the auditory cortex in comparison to a group receiving leader-
ship training. Futher, they observed improved phonological
awareness, but not phonological memory or rapid naming in the
group receiving musical training compared to leadership training.
Musical training across life has been shown to be associated with
faster neural timing in response to speech in late adulthood
(White-Schwoch et al., 2013).
Most of the research focusing on music-induced enhancements
of brain responses to sounds or performance in neuropsychological
tests has used adult-led or computerized musical training. Such
training is straightforward to quantify in terms of minutes or hours
of training per day or per week. Informal musical activities, in
contrast, are difficult but not impossible to quantify. Putkinen et al.
(2013) formulated a large questionnaire tackling all possible types
of musical activities that a child can spontaneously engage herself
or himself in, with the parents, siblings and friends, or alone. A
comparison of the amounts of such informal musical activity to
brain responses recorded in a distractive-sound paradigm which
measures the brain responses to surprising, attention arousing
sounds showed smaller distraction-related brain responses in
children with the largest amount of informal musical activities. This
was interpreted as a more developed attention-allocation system to
relevant and irrelevant sounds. Auditory attentive skills are highly
relevant for language learning, since all sensory modalities (audi-
tory, visual, tactile, even taste and smell) constantly send a myriad
of stimulation, only a fraction of which reaches the working
memory and can thus be effectively learnt (Cowan, 1988; Gomes
et al., 2000).
It should be noted, however, that in many of the studies
described above, the musical hobbies were chosen by the children
and their families. Children who choose musical hobbies often
come from families with a higher-than-average socio-economic
status (Hartas, 2011). Even though this is typically compensated for
in the control group and in the statistical analysis, interventional
studies where children are randomly allocated to musical learning
and other types of hobbies are the strongest studies when it comes
to the causality of the effects.
Jaschke et al. (2018) randomised 6-year-old children (n ¼ 147) to
two musical intervention groups, one active visual arts group, and a
no-arts control group. For the musical intervention (1e2 h/week),
early lessons introduced melody, meter and rhythm as well as
different musical instruments. The lessons started with a
welcoming song, followed by music theoretical and historical in-
formation in the context of the song and ended with collective
music making, singing, playing and improvising. The children were
followed for 2.5 years. Development of verbal intelligence and ex-
ecutive functions as well as academic performance were assessed
for each group. Test scores for executive functions (inhibition and
planning) and verbal intelligence increased significantly more for
the two music groups than for the visual art and no-arts controls.
Recently, Linnavalli et al. (2018) found similar improvement of
verbal intelligence (Vocabulary, Block design and Matrix reasoning
subtests from WISC IV), and additionally, phoneme processing,
while not of executive functions (inhibition from NEPSY II test
battery) for children whose kindergartens offered musical play
school (where activities include singing and musical instrument
playing) as a weekly routine. They did not find similar improve-
ments for children in two types of control groups (in kindergartens
offering dancing activities or no extra training). Thus, both of the
studies above and the study of Moreno et al. (2011) indicate that
musical activities offered to randomly chosen children improve
verbal intelligence (vocabulary skills) while evidence for the
improvement of non-verbal intelligence and executive functions is
unclear (for a review, see Linnavalli et al., 2018).
The majority of studies investigating the perception of speech in
noise by musicians and non-musicians show improvements for
musicians (for a review, see Coffey et al., 2017). There is also evi-
dence for improvement of perception of speech in noise with
musical training for normally hearing children. Slater et al. (2015)
conducted a study using children participating in community-
based musical activities (age approximately 7 years at the begin-
ning of the study). After a first assessment using the Hearing in
Noise Test (HINT), participants were randomly assigned to one of
two groups: one group began musical training right away and
completed 2 years of training (including singing and musical in-
strument playing), while the second group waited a year and then
received 1 year of musical training. It was found that speech-in-
noise perception improved only for the group receiving 2 years of
training.
There is also much evidence on the effects of musical training,
including singing and musical instrument playing, on phonological
awareness (for a meta-analysis, see Gordon et al., 2015), including
controlled intervention studies (Flaugnacco et al., 2015; Patscheke
et al., 2018). Interestingly, Patscheke et al. (2018) compared
rhythmic training with musical instruments (no singing) to pitch-
based training with singing. They found that phonological aware-
ness improved only with singing training.
All in all, the studies reviewed above and several others show
that musical training, be it instrument training, singing or musical
play school, and informal musical activities all enhance the devel-
opment of the auditory system in childhood and adolescence, and
that such enhanced development is in many cases accompanied by
improved language-perception skills. Advancing language devel-
opment and communication in general is, however, not the only
use of music. Humans use music for several other reasons, such as
relaxation, well-being, inspiration, social cohesion, and building
and communicating cultural norms and systems (MacDonald et al.,
2002; Saarikallio, 2011; Saarikallio and Erkkila €, 2007). All of these
should be taken into account when considering the rights and
needs of children to be involved in the world of music - whether
they have typical hearing or are users of different types of hearing
aids or implants.
Children with hearing impairment have deficits in auditory
attention (Fagan and Pisoni, 2009; Houston et al., 2003), in auditory
working memory and in perception of spectral details (for an
overview, Torppa et al., 2014a), similarly to adults with hearing
impairments (Moore, 2003). These evidently partially underlie
their difficulties in perception of phonemes (Eisenberg, 2007),
speech in noise (Asp et al., 2012; Caldwell and Nittrouer, 2013;
Moore, 2003), simultaneous sounds, sound localization, and
perception of pitch and prosody (word and sentence stress, Lyxell
et al., 2009; O’Halpin, 2010; emotional prosody, Kalathottukaren
et al., 2017; question vs. statement intonation, Peng et al., 2008).
They often lag behind typically hearing children in language skills,
such as expressive and receptive language skills (Fitzpatrick et al.,
2011), vocabulary (Lund, 2016; Percy-Smith et al., 2013; Va €limaa
et al., 2018), expressive morphological and syntactic skills (Boons
et al., 2013; Soleymani et al., 2016), production of narratives
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
(Boons et al., 2013), phonological awareness (Ambrose et al., 2012;
Soleymani et al., 2016), and verbal intelligence (Geers and Nicholas,
2013; Hashemi and Monshizadeh, 2012; Wu et al., 2008).
From the evidence reviewed above, showing how music-related
exposure and training can enhance the activity of the auditory
system and the brain, as well as auditory attentive, language, and
learning performance, it is tempting to suggest that music should
be used as a rehabilitation method for children with varying types
of hearing impairments, both to help them enhance their speech
and language skills, and to advance their skills in hearing in general.
It has indeed become increasingly common to use music as part of
speech therapy and as part of the general rehabilitation of these
children. For example, Auditory Verbal Therapy (AVT, Estabrooks,
1994), the Hanen program (Manolson, 1992), the Lindfors Foun-
dation MUKULA-project (http://lindforsinsaatio.net/) in Finland,
and several materials (like STEPS Together, http://www.
earfoundation.org.uk/shop/items/76, Baby Beats, Rocca, 2015)
emphasize the role of music and especially singing in auditory and
language rehabilitation. The Mary Hare School in the UK has for
several years used music as an integral part of the education of deaf
children (Rocca, 2012). It is, however, crucial to investigate the
outcome of such music-related methods, preferably using inter-
vention studies with control groups and with children randomly
allocated to the intervention and control groups, and preferably
with long-term follow-up of the development of speech and lan-
guage skills. Such studies are very demanding. In the following, we
describe studies that report any type of effect of using music with
hearing-impaired children.
2. Musical activities and children with hearing impairments
Only a few studies have addressed the correlation of musical
activities with speech perception or language skills for children
with hearing impairments. Moreover, Gfeller (2016) concluded that
there is no evidence from randomised, fully controlled intervention
studies on the impact of musical training interventions on speech
perception or language skills of children with CIs. This is in strong
contrast to the musical intervention studies showing the impact of
musical training on speech perception and language skills of chil-
dren with typical hearing, reviewed above.
One major reason for the lack of intervention studies is the small
population of children with CIs and with other hearing impair-
ments compared to typically hearing children. Another reason is
that families with hearing-impaired children may live long dis-
tances from each other, and they typically have to visit clinics, also
far from home, for tuning of the hearing aid or CI. The families are
also busy with rehabilitation, like speech and language therapy.
Therefore, they may not have the resources needed to take part in
an intervention study. All in all, research with large-scale rando-
mised controlled trials (RCT) in CI users and hearing-impaired
children and adolescents is scarce.
Due to the lack of RCTs, it is necessary to assess the correlational
and longitudinal evidence, which hopefully provides a basis for
future large-scale intervention studies. Moreover, musical activities
at home are enjoyable and typical for children with both normal
and impaired hearing (Driscoll et al., 2015). The important role of
parents and home activities in auditory rehabilitation and in speech
and language therapy for children with hearing impairments is well
known (Hull, 2013; Estabrooks, 1994). Thus, it is also important to
inspect how informal musical activities at home might improve
speech perception and language skills in children and adolescents
with hearing impairment or CIs.
Results for the perception of pitch (the perceptual correlate of
fundamental frequency, f0) are included in this review because f0 is
an important cue for the perception of prosodic stress, also for
111
children with CIs (Torppa et al., 2014a). Perception of stress, in turn,
is an important feature in assisting speech segmentation (on the
role of prosodic stress, see Jusczyk et al., 1999), speech perception
(on the role of stress and word stress patterns, i. e., speech rhythm,
see Bolger et al., 2014; Mattys, 1997; Scho€n and Tillmann, 2015) and
language learning (on the role of word and sentence stress, see
Cutler and Foss, 1977; Ma €nnel and Friederici, 2013; Thiessen and
Saffran, 2007). Because hearing impairments often lead to deficits
in the perception of pitch (Oxenham, 2008), improving the
perception of pitch and prosody with musical activities is especially
important for hearing-impaired children. We also include studies
assessing the perception of musical rhythm since, for normal-
hearing adults, this is connected to the perception of word stress
(Hausen et al., 2013) and speech in noise (also for children with CIs,
see Torppa et al., 2018). Due to this connection, an improvement in
the perception of musical rhythm may be of importance also for
language perception. Furthermore, we assess the possible con-
nections between speech-in-noise and music perception, since
these connections are thought to be a prerequisite for musical
training to improve speech perception and language skills (Besson
et al., 2011; Patel, 2014).
2.1. Correlational and cross-sectional studies
Correlational studies related to speech perception or language
skills are presented in Table 1. Cross-sectional studies are included
in Table 1 and in the current section since, even though they give
information about links to musical activities, similarly to other
correlational studies, they cannot address causality.
Correlational and cross-sectional evidence for hearing-impaired
children shows better perception of pitch (Chen et al., 2010) and
music (cued with changes in f0 or duration; Polonenko et al., 2017)
with longer duration of musical training (listening, singing, or
musical instrument playing; Table 1).
Two studies have assessed connections between the perception
of speech and of music, with different measurements and results.
Koşaner et al. (2012) failed to find connections between speech and
music perception assessed with a questionnaire (music questions:
singing skills, recognizing songs, tunes, and timbre) for hearing-
impaired children (see Table 1). Torppa et al. (2018) examined
whether the cortical processing of musical instrument sounds for
children with CIs is correlated with the perception of speech in
noise. For the entire group of children with CIs, the perception of
speech in noise was better for children with larger mismatch
negativity (MMN) brain responses (improved neural discrimina-
tion) to a change of sound from piano to cymbal (musical instru-
ment timbre). For the children with CIs who sang regularly at home,
“CI singers” (for details, see Table 1; see also section 2.3), speech-in-
noise perception was better for children with earlier P3a responses,
reflecting an attention shift towards sound changes salient for the
listener, for all three changes in musical instrument (from piano to
cembalo, violin and cymbal).
Torppa et al. (2010; Table 1) found that, for children with CIs, the
perception of sentence and word stress was better with more
parental singing and with more musical instrument playing at
home, while the perception of sentence stress was also better with
more participation in music play school-like activities. The corre-
lation of stress perception with listening to music from television or
CDs was not significant.
Rochette et al. (2014) conducted a cross-sectional study of
prelingually deaf children who used CIs and/or hearing aids. They
compared children attending musical activities for several years
(see Table 1) to those who did not participate in musical activities.
They found that compared to children with no musical training,
children with musical training performed better in tasks measuring
112 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122

Table 1
Correlational and cross-sectional studies in children with hearing impairments

Study N, age, device Design of the study Measurements Results

Studies investigating relationships of musical training with pitch and music perception only
Chen et al., (2010) N ¼ 27 (13 in musical 13 CI children attended YAMAHA Music Test stimuli consisted of 2 For all children, pitch (f0) perception
training), age 5e14 years, School for 2e36 months with NH sequential piano tones, ranging was better with longer duration of
CI. children; listening, singing, score from C (256 Hz) to B (495 Hz). musical training. (Pitch (f0) perception
reading, and instrument playing. Children identified the pitch (f0) was better in children older than 6
Correlations of pitch (f0) perception relationship between the 2 tones years vs.  6 year and with larger pitch
with duration of musical training (and (same, higher, or lower). In intervals; no correlations between pitch
with current age, age at first CI, gender, statistical analyses, children divided perception and the age at first CI,
and type of CI) were studied. into older than 6 years vs.  6 years. gender, or type of CI).
Polonenko et al. N ¼ 50. 26 bilateral CI, 8 Performance of 26 CI, CI þ HA, NH MBEMA (iPad application). For first Children who had participated in
(2017) CI þ HA, children was compared. Interviews 4 subtests (ST): Discrimination musical training were faster and more
16 NH children; age 6e18 showed that 12 bilateral CI and 2 between different or similar accurate in music perception,
years. CI þ HA, and 11 NH children had melodies: The note changed to an regardless of their hearing status.
participated in musical training 1e10 out-of-key note (Scale ST), changed Reaction time on specific subtests
years: music theory classes, practicing the pitch direction (Contour ST), the decreased with years of musical
at least one non-percussive instrument, interval while maintaining the training, age, and, for CI users, better
and/or singing training. To determine same scale and contour (Interval ST) residual hearing.
the results for effect of musical training, or the duration between notes
in RM ANOVA (controlling for age), the (Rhythm ST). In the last ST
between-subject factors were hearing (incidental Memory), the children
group (normal and bilateral device indicated if they had heard the
hearing) and music group (no musical excerpt before or not. 2 practice and
training, musical training). 20 test items for each ST.
Studies investigating relationships with perception of prosody
Torppa et al., (2010) N ¼ 17, age 4e12 years, CI. Correlations of amount of parental Perception of compound vs. phrasal In the CI group, better sentence stress
(The same subjects as in the singing and other musical experience at stress (word stress) and narrow perception correlated strongly with
larger sample in Torppa home with children's perception of focus (sentence stress). more parental singing and less strongly
et al., (2014a,b), 2018, in word stress and sentence stress were Questionnaire assessing musical with playing more a musical instrument
print. studied. Duration of experience on and hearing-related background. at home. Sentence stress perception
parental singing: up to 9 years, starting was better with more participation in
from implantation. Performance was musical play school -like activities.
compared for children participating in Word stress perception was better with
musical play school -like activities and more parental singing and playing
those who did not participate in these. instruments. Correlations with listening
to music from television or CDs not
significant.
Studies investigating relationships with perception of speech in quiet and noise
Koşaner et al., 2012 Group A: N ¼ 12, age 19e37 Correlations of speech perception with Auditory speech perception from Correlations of scores on the subscales
(see also Table 2) months; Group B: N ¼ 7, music perception (and age at first CI the EARS test or from LEAQ. ‘Recognizing songs, tunes, timbre’ with
age 34e60 months; Group fitting, length of CI use, and Evaluation form, filled in by LEAQ or LiP scores (Group A)/scores on
C: N ¼ 6, age 49e91 chronological age) were investigated in teachers: Singing skills, the Bisyllabic Closed-Set speech
months. CI. children participating in musical Recognizing songs, tunes, and perception (Group B) not significant. (A
intervention, separately for subgroups timbre; Responding to music and significant correlation between Total
(A and B). rhythm. evaluation score and length of CI use for
both groups; Correlations with age at
first CI not significant).
Rochette et al., N ¼ 28, age 6e10 years, CI Performance was compared for 14 Sound identification; Auditory Musically trained children were better
(2014) and/or HA. children with HI without musical stream segregation task (changing in auditory stream segregation,
activities and 14 HI children who had or not-changing simultaneous auditory working memory and
participated 1,5 to 4 years in group animal sound streams); Auditory phonemic discrimination tasks.
music lessons (5e6 children in each), working memory task (reproducing Multiple-regressions suggested that
using voice and musical instruments, sounds using the keyboard); Same- good performance was at least partly
sensomotor activities with music, different identification of mono- or driven by music lessons.
musical exercises involving memory, bisyllabic nonsense words with
analyzing the emotional value of different phonemes.
musical pieces, playing simple self-
written pieces of music together.
Assignment to groups based on type of
hearing devices. Groups did not differ
significantly in age, age at HI correction,
duration of device use and type of
correction (HA/CI).
Torppa et al., (2018) N ¼ 21, age 4e13 years, CI. Relationships of perception of speech in SRT for 75% correct words in The perception of speech in noise in
(see also Table 3) noise with ERP responses (MMN and sentences in steady male-weighted children with CIs was better with larger
P3a) and discrimination of pitch and noise. MMN (preattentive amplitude of MMN to a change of sound
intensity in synthesized bisyllables discrimination of) and P3a from piano to cymbal, and in the CI
were analyzed with LMM (age (attentions shift towards) changes singing group only, with earlier P3a to
controlled for) where group factor in f0, intensity and timbre; changes in timbre.
“singing” was included (12 CI children discrimination of f0 and intensity in
who sang regularly and vs. 9 CI non- synthesized bisyllables.
singers) (see Table 3). Duration of
singing experience (parental/child): up
to 10 years, starting from implantation.
Studies investigating relationships with language skills
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122 113

Table 1 (continued )

Study N, age, device Design of the study Measurements Results

Torppa et al. in N ¼ 21, age 5e13 years, CI; In 21 children with CIs, and 31 children Word finding test, WISC vocabulary In the CI children, all language skills
print NH reference group. with NH, the relationships of word and (VIQ), production of rhymes were better with more musical
sentence stress perception, formal (phonological awareness). activities, and word finding and VIQ
musical activities with emphasis on improved with more parental singing
singing (CIm/NHm group) vs. others and better stress perception. Similar
(CIn/NHn group) and parental activities associations of word finding and VIQ
(singing, reading, other activities) with with musical activities were found for
language skills were investigated with children with NH. For all children, all
linear regression analysis (for the language skills improved with better
musical training in the CI group, see stress perception.
Table 3, Torppa et al., 2014a).

N ¼ number of participants. CI ¼ cochlear implant, HA ¼ hearing aid, NH ¼ normal hearing. HI ¼ hearing impairment. F0 ¼ fundamental frequency; pitch is perceptual
correlate of f0. EARS ¼ the Evaluation of Auditory Responses to Speech test battery. LEAQ ¼ LittlEARS Auditory Questionnaire. LiP ¼ Listening Progress Profile; Nikolopoulos
et al., 2000. MBEMA ¼ Montreal Battery of Evaluation of Musical Abilities (Peretz et al., 2013). RM ANOVA ¼ repeated measures analysis of variance. LMM ¼ linear mixed
modeling. VIQ ¼ verbal intelligence quotient, measured with vocabulary subtest of the WISC-IV (Wechsler, 2010). ERP ¼ event-related potential. MMN ¼ mismatch negativity
brain response. P3a ¼ positive response peaking after MMN, reflects attention shift towards sound change.

auditory working memory, in auditory scene analysis, and in pho-
netic discrimination. Multiple-regression analyses indicated that
the improved performance was partly driven by the musical
training.
For normally hearing children several RCT studies have shown
improvements in language skills with musical activities (see sec-
tion 1.2). RCT studies assessing this issue in children with hearing
impairments are still lacking. However, Torppa et al. (in print)
found that musically active children with CIs (at age 5e13 years),
after participation in singing and playing at home and outside of
the home for several years, performed better than other children
with CIs in word finding, verbal intelligence (WISC vocabulary; the
same task as in Linnavalli et al., 2018; Moreno et al., 2011, see
section 1) and phonological awareness measured with production
of rhymes (see Gordon et al., 2015, and section 1.2), while musically
non-active children performed more poorly (Torppa et al., in print;
Table 1). Similar results on improved language skills for musically
active children (for word finding and verbal intelligence) were
found for an enlarged normal-hearing group at a similar age. For CI
and normal-hearing groups, all language skills improved with
better perception of prosodic stress, giving evidence that percep-
tion of prosody assists language learning of both child groups
(previous evidence for normal-hearing children, see Ma €nnel and
Friederici, 2013; Cutler and Foss, 1977; Thiessen and Saffran,
2007). It was also found that parental singing was correlated
significantly with word finding and verbal intelligence, but only for
the children with CIs (Torppa et al., in print).
2.2. Intervention studies without a control group
There are several intervention studies without a control group
where performance over time of one group of children with hearing
impairments participating in musical intervention has been fol-
lowed (Table 2). Such studies measure the effect of two things:
development of auditory or musical skills related to musical
learning, and the development of the same skills related to general
maturation and to exposure to speech, practicing of speech and
language skills, and so on. In such a study, it is impossible to
disentangle these two effects.
Two of these studies have assessed how the development of
auditory perception is related to music perception (Table 2). Fu
et al. (2015) assessed whether melodic contour training using a
home computer could improve the perception of melodies for 5e10
year old children with CIs. After 4 weeks of intensive training,
perception of melodic contours markedly improved. Measurements
8 weeks later showed no decline in performance. Innes-Brown et al.
(2013) studied development of the perception of musical pitch,
timbre and rhythm, and the role of device/hearing in the devel-
opment of these, for children with CI and/or HAs and normal
hearing (age 9e13 years) participating in a weekly Music Club at
school. No development in test performance was found.
Koşaner et al. (2012) designed, implemented, and evaluated an
18-month family-centered rehabilitation program (Musical EARS®).
The program evaluation form included sections on singing, recog-
nizing songs, tunes, and timbre, and responding to music and
rhythm. Development in these skills and speech perception (from
questionnaires) was assessed. Mean total scores in an evaluation
form for musical skills increased for preschool-aged children, while
the scores for speech perception did not improve significantly. Lo
et al. (2015) conducted two melodic contour training programs
and studied their effects on speech perception for 16 adults with CIs
and 12 adults with normal hearing. One program manipulated
musical interval sizes, and the other program manipulated note
durations. Both programs lasted for 6 weeks. There was improve-
ment in speech perception only for CI users in both melodic
training programs. Specifically, consonant perception in silence and
question/statement prosody was improved. Normal-hearing lis-
teners performed at ceiling for these tasks. No improvement was
found for speech perception in noise for either of the groups.
Several studies reported in Table 2 showed that musical activ-
ities seem to be enjoyable for children with hearing impairments
and their families. Abdi et al. (2001) and Rocca (2012) reported
enhancement of musical instrument playing and other musical
skills with musical training for children of various ages. Koşaner
et al. (2012) and Rocca (2015) studied musical programs targeted
for very young children with CIs and their families. Koşaner et al.
(2012) found that participation in and enjoyment of musical ac-
tivities increased for both children and parents. Rocca determined if
the program could be used for babies, and found that parents
observed increased vocalisation, attention, and anticipation of the
activities in their babies, and increased confidence in singing,
moving, and playing with their baby, including during daily rou-
tines. The reports of the teachers of children participating in the
study of Innes-Brown et al. (2013) suggested that participation in
the Music Club improved children's confidence with voice, psy-
chosocial development, social engagement with peers and
involvement in general music classes (Table 2).
2.3. Musical interventions with a control group
This section introduces results from musical intervention
studies with several study and intervention designs, all including a
Table 2
Intervention studies without control group.
Study Device/age and N Type and size of music group/duration
of intervention
General goal: To improve music (pitch/f0) perception
Fu et al. (2015) CI 6 CI children in computer-based
/5e10 years, melodic contour identification (MCI)
N ¼ 6 in intervention, (8 CI home training. They trained 5-tone
children not in musical complex or piano sample melodic
training; no comparisons contours with 23 root notes.
between intervention and /A half hour per day, every day for a
non-intervention groups). period of 10 weeks.
General goals: To study and develop a music program, and the development of musical skills and/or music perception
Abdi et al., CI All CI children participated in a music To assess the feasibility and methods of
(2001) /2,5e12,5 years, program based on Orff method and se-
N ¼ 23. tar playing.
/3 to 13 months, 1 lesson per week.
Rocca (2012) CI and/or HA Music program of Mary Hare School.
/NA. Parents of babies and preschool
children are encouraged to integrate
musical activities into their daily
routine. Music theory, playing and
singing in group settings and individual
music instrument/singing lessons.
/Weekly music lessons up to the age of
14.
Innes-Brown CI, CI þ HA, 2 HAs All children participated in a weekly
et al., (2013) /9e13 years, N with CI or Music Club during lunch time at school
CI þ HA ¼ 6, N with 2 45 min per week: vocal play, the
HAs ¼ 5, N with NH ¼ 4 (in integration of aural, visual, and
tests, 15e17 children/per kinesthetic modes of learning: Kodaly
time point). method.
/A school year.
General goals: To study and develop a music program; development of musical skills, speech perception or language skills
Koşaner et al., CI All children participated in Musical
2012 /Group A: N ¼ 12, age 19 EARS® program: singing, recognizing
e37 months; Group B: songs, tunes and timbre, and
N ¼ 7, age 34e60 months; responding to music and rhythm.
Group C: N ¼ 6, age 49e91 Activities introduced in group sessions
months. were repeated in individual sessions
and parents were encouraged to repeat
activities at home. Recorded music was
mostly used.
/18 months.
Rocca (2015) Pre-CI group: All children participated in Baby
HAs, post-CI group, CI or BeatTM program for parents and babies.
CI þ HA. Aims to elicit in deaf babies musicality Program is designed to improve parent
N ¼ 15. through the use of backing tracks and
/age 5e11 months. the parent's voice. 4 key areas: music
and movement, instrumental (timbre)
& music/singing, early symbolic sounds,
musical symbolism. Imitation of the
vocalisations of Ling sounds and words,
their anticipation.
/8 months.
N ¼ number of participants. CI ¼ cochlear implant. HA ¼ hearing aid. LMM ¼ linear mixed modeling. ANOVA ¼ analysis of variance. F0 ¼ fundamental frequency; pitch is perceptual correlate of f0. EARS ¼ the Evaluation of
Auditory Responses to Speech test battery; LEAQ ¼ LittlEARS Auditory Questionnaire. MCI ¼ melodic contour identification. NA ¼ not applicable. IAMMA ¼ Intermediate Measures of Music Audiation (Gordon, 1979).
Specific goals/statistical analyses
The improvement of musical pitch/
melodic contour perception./ANOVA for
assessing development of the musical
intervention group.
utilizing music as a means of
habilitation of children with CIs./Case
studies; no statistical analyses.
To describe the benefits of the music
program for social communication
skills and musicality.
/No statistical analyses.
To assess the development of
perception of musical pitch, timbre and
rhythm to assess the role of device/
hearing for the development.
/LMM.
To increase the quality and quantity of
musical activities in habilitation;
feasibility of the evaluation tool./
ANOVA.
To determine if the program could be
used to monitor outcomes for babies.
interaction, listening behaviour,
communication, social and emotional
development, pre-post-implantation./
No statistical analyses.
Outcome measures
The participants identified changes in
melodic contours (5tone, 3tone, and
5piano sample stimuli). They clicked on
one of the nine response choices on the
screen; response boxes were labeled
and included an illustration of the f0
contour pitch direction.
Teachers rated musical skills and
responsiveness to music.
The UK National program of the Early
Years Foundation stage profile is used at
Mary Hare. The article gives a general
overview of the development of
musical skills.
Tonal, rhythmic tests from IMMA;
timbre perception test.
Evaluation form, filled in by teachers:
Singing skills, recognizing songs, tunes,
and timbre; responding to music and
rhythm. Auditory speech perception
from the EARS test or from LEAQ.
Questionnaires for parents and
professionals, completed at the end of
an 8-month trial.
114
Results
After 4 weeks of training, MCI
performance sharply improved for all
test stimuli. Performance did not
decline during 8 weeks after training
stopped. (For the 6 trained subjects,
there was a significant effect of contour
length).
All children improved in playing se-tar.
Musical skills and responsiveness to
music were reported to increase; all
parents expressed their satisfaction
with the program.
Many children with CIs can play, sing,
R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
and participate confidently in social
musical contexts. Some past student
recipients have trained at universities
in the United
Kingdom to become music teachers,
performers, and composers.
Improvement in test performance was
not significant. Teachers reported that
participation in the Music Club
improved children's confidence with
voice, psychosocial development, social
engagement with peers and
involvement in general music classes.
Evaluation form scores increased
significantly: increase of speech scores
not significant. Participation in and
enjoyment of musical activities
increased for both children and parents.
The program was appropriate for babies
and for parents' use at home. Parents
observed increased vocalisation,
attention, and anticipation of the
activities in their babies, increased
confidence in singing, moving, and
playing with their baby, also during
daily routines.
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
control group with a minimal amount of musical activities or
training (Table 3; note that Welch et al., 2015, used a normal-
hearing reference group which had only slightly less musical ac-
tivities than the hearing-impaired intervention group). This section
also describes results from adults with CIs, one study comparing
auditory learning and auditory-motor learning related to lyrics (not
included in Table 3), and one study where hearing-impaired chil-
dren served as controls for themselves (AB-BA design, Hidalgo et al.,
2017, Table 3).
Not all intervention studies with a control group showed im-
provements with musical training on perception of music or
prosody-related auditory cues, or speech perception. Petersen et al.
(2015) conducted a musical intervention (rhythm, singing and ear
training and computer-based exercises, Table 3) using adolescents
with CIs. Normal-hearing adolescents served as control subjects.
The duration of the intervention was 6 days (20 h), distributed over
2 weeks. They measured mismatch negativity (MMN) brain re-
sponses for changes in f0, rhythm, intensity and timbre, behavioral
discrimination of these same features, and speech perception in
noise. No improvement with training was found (see also Innes-
Brown et al., 2013, Table 2, for null results).
There are studies indicating improvements with musical
training in music perception and musical skills but not in speech
perception. In the pioneering study of Yucel et al. (2009, Table 3),
parents trained their recently cochlear-implanted children at home
using a keyboard (f0 and rhythm discrimination exercises) and
encouraged their children to listen to and dance with simple, re-
petitive melodies (Table 3). Compared to children without musical
training, the musical intervention group was better in open-set
speech perception (measured with repetition of sentences) three
months after the training began. However, at the end of the 2-year
training period there were no differences between groups in
speech perception. By the end of the second year, the results from a
questionnaire indicated that the music group was better than the
control group in all aspects of musical skills, including singing
melodies and producing rhythms, thus indicating improvement in
the perception of pitch and rhythm with musical training. Welch
et al. (2015; Table 3) found rather similar results with singing
training (most often in a music class for 29 children, and occa-
sionally in small groups) with 5-7-year-old hearing-impaired
children. Normally hearing children participated in class-based
singing training, but they did not have training in small groups
(see Table 3). It was found that the comfortable singing range,
general ability to sing (pitch and rhythm patterns) and pitch
perception improved only for the children with hearing impair-
ments. They found no improvement in perception of speech in
noise, which the authors interpreted as being due to the context:
classrooms with normal-hearing and hearing-impaired children
learning together in quite large groups. Moreover, Petersen et al.
(2012) found in a controlled musical intervention study (training
6 months, singing, playing piano, computer-based listening), using
adults recently implanted with cochlear implants, improvements in
music perception (discrimination of timbre, melodic contour, and
rhythm) only for the musical intervention group. However, the
perception of speech in noise and emotional prosody improved
similarly in both musical intervention and control groups. The
improved perceptual and musical skills with musical intervention
from the two studies above are in line with the correlational results
(Chen et al., 2010; Polonenko et al., 2017, Table 1) and results from
interventions without a control group for children with CIs (Abdi
et al., 2001; Fu et al., 2015; Koşaner et al., 2012; Rocca, 2012,
Table 2).
The positive results above are also in line with the results from a
study which investigated how singing at home is related to the
development of cortical processing of music and attention in 4e13-
115
year-old children with CIs (Torppa et al., 2014b, Table 3). It was
assessed how P3a brain responses, reflecting attention shift to-
wards sound changes, developed over 14e17 months in those
children with CIs who sang informally and regularly at home (“CI
singers”), and those who sang only rarely. The only factor
explaining CI-children's singing was that their parents had sung
more for them from their early childhood (Torppa, 2015, p. 56;
Table 3). The P3a was elicited by a change in a sound sequence with
a regular and predictable rhythm. The CI singers had consistently
larger and earlier P3a responses than the CI non-singers. The largest
and most statistically significant differences between groups were
found for the P3a responses to changes in musical instruments
(timbre) and f0. The P3a responses became larger and earlier during
the follow-up period for the CI singers only. It was also found at the
second time point of the measurements that the CI singers sang the
rhythms of a children's song (“Twinkle twinkle little star”) better,
indicating better perception of rhythm for them than for the CI non-
singers. These results suggest that informal singing at home could
lead not only to better music perception but also to better auditory
attention (Torppa et al., 2014b).
Only one study reported improved perception of speech in noise
with musical activities for children with CIs (for null results, for
hearing-impaired children, Petersen et al., 2015, and Welch et al.,
2015, Table 3; for adults, Lo et al., 2015, see section 2.2 above;
Fuller et al., 2018; Petersen et al., 2012). Torppa et al. (2018; Table 3)
studied how CI singers (who sang informally and regularly at home)
and CI non-singers developed in the perception of speech in noise
during 14e17 months. It was expected that compared to the CI non-
singers, the CI singers would perceive speech in noise better, since
their attention shift towards sound changes was improved, and
attention is important for the perception of speech in noise, and
also because they sang rhythms better (for more details, Torppa
et al., 2018). As expected, the CI singers had better speech
perception in noise than the CI non-singers, which is in line with
results from normal-hearing children, showing improvement of
perception of speech in noise with long-term (2 years) musical
training, including singing and musical instrument playing (Slater
et al., 2015; see section 1). However, in the study of Torppa et al.
(2018), compared to the CI non-singers, the CI singers did not
develop in this skill more during the follow up. It was concluded
that even though the results could not address causality, a
connection was found between improved speech perception in
noise and long-term singing at an early age of the CI singers, by
children themselves and/or by their parents. The study (and the
study of Torppa et al., 2014b) could not differentiate the role of
parental singing from the singing of the children themselves, since
these two were strongly connected (Torppa, 2015). It is worth
noting that the parents often sang face to face with the child. This
could improve attention to spectral changes because the child
could see the mouth and lip shapes and movements, which are
related to the spectral content of consonant and vowel sounds. The
slow rate and predictability of children's songs may be particularly
beneficial for the perception of these spectral changes. However, it
cannot be ruled out that better perception of the sound intensity
envelope (important for rhythm perception, for which the CI
singers were better than the CI-non-singers; Torppa et al., 2014b)
also plays a role, since this is known to be an important cue for
perception of speech and for perception of musical instrument
timbre, especially for CI users (Drennan and Rubinstein, 2008; Kong
et al., 2011).
Since the CI singers sang the rhythms of a song better than the CI
non-singers, it is possible that the CI singers could benefit from the
regular rhythm of the stimuli (see above, Torppa et al., 2014b). Their
auditory system may have been better able to track the moments
when important information was expected. Triggered by the
Table 3

116
Intervention studies with a control group.

Study Size and type of control group/ Device Size and type of music group Specific goals Outcome measures Results
allocation to control and music /age /duration of intervention /statistical analyses
groups

General goals: Music perception (pitch/f0) and auditory attention

Torppa et al. 9 CI peers did not sing at home (CI CI
2014b non- singers). No differences from /4e13 years.
the CI singers with respect to other
musical background than parental
singing (parents of CI non-singers
sang less), age, hearing-related
aspects, CI type, age at CI, gender,
socio-economic background,
etiology.
/Based on a questionnaire.
General goals: Music perception and/or perception of prosody
Torppa et al., 13 CI peers (CIn children) with non- CI
12 CI children (CI singers) sang
regularly at home before and
between tests; regular parental
singing starting from implantation
/first tests (T1) at age 4e13 years,
second tests (T2) 14e17 months
later.
/Total duration of singing to 10
years (on average 5 times per week
before T1, 4 times per week
between T1/T2).
8 CIm children in musical play
Development of preattentive
discrimination and attention
shift toward changes in musical
tones. Accuracy of singing at T2.
/LMM.
Perception of prosody and
Event-related potentials: MMN,
P3a for changes in pitch (f0),
timbre, duration, (intensity)
and gaps in every other tone;
evaluation of accuracy of
singing (f0, rhythm and lyrics)
of the CI children.
Perception of word and
Only CI singers developed in
attention shift (P3a), significantly
towards changes in timbre;
Compared to CI non-singers, CI
singers had larger and earlier P3a
for changes in pitch (f0) and earlier
P3a for changes in timbre, and they
sang better rhythms of songs.
CIm children performed similarly to

R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122

(2014a) musical hobbies. Compared to /4e13 years. school-like activities with parents auditory cues for prosody (f0, sentence stress; discrimination NH controls in stress and pitch (f0)
music group, parental education or alone (small groups) þ home intensity, duration). of f0, intensity and duration in perception in bisyllables (and digit
lower, which was controlled for in activities ¼ singing by parents and /LMM. synthesized bisyllables; digit span). CIn children performed more
all statistical analyses. No children, playing instruments, span forward, PIQ. poorly than CIm and NH groups.
differences from the music group dancing Only CIm children improved with
with respect to age, hearing-related /starting from implantation, first age in word stress and intensity
aspects, CI type, age at CI, gender, tests (T1) at age of 4e13, second perception in bisyllables, and
etiology. tests (T2) 14e17 months after. improved over time in digit span.
/Based on a questionnaire. /Total duration up to 10 years.
Weekly þ musical activities at
home.
Good et al., (2017) 9 CI peers in visual arts training. No CI 9 CI children in individualized, Perception of music and MBEMA (scale, contour, Musical training enhanced:
difference from the music group /6e15 years. private piano lessons: technical emotional speech prosody. interval, rhythm, and incidental discrimination of melodic contour,
with respect to age, age at CI, CI exercises with piano, music theory /Mixed-design ANOVA. memory), perception of rhythm, memory for melodies, and
experience, speech perception./ rudiments, learning songs and emotional speech prosody emotional prosody especially in
Pseudorandom or random rehearsal of the (audio-only audio-only task. Art training did not
allocation. songs vocally. and audiovisual). lead to the same improvements.
/6 months.
Hidalgo et al., The same HI children participating a CI and/or HA Rhythmic and audio-motoric Temporal adaptation in speech Picture naming in alternation Children with HI became sensitive
(2017) speech therapy session. /5e6 years. exercises: following the beat of the interaction. with a virtual partner. to the manipulation of temporal
/AB-BA design. song (clapping the hands, shaking /RM ANOVA. Alternation rate and temporal regularity of stress occurrences only
maracas, body tapping, imitating predictability (match vs. after rhythmic training.
different rhythms of songs, mismatch of stress occurrences)
presented by the speech therapist were manipulated.
on a djembe.
/30 min.
General goals: Music perception and/or perception of speech in quiet or noise
Yucel et al., (2009) 9 CI children without musical CI, CI þ HA 9 CI children. Parents trained their Pitch (f0) and rhythm Meaningful auditory By the end of 3rd month, music
intervention. /newly implanted, children at home to recognize pitch perception; speech perception. integration scale (MAIS) or group was better in open-set
Newly implanted, the age at the age at (f0) differences between notes and /Mann-Whitney U-tests. infantetoddler MAIS and the speech perception.
implantation ranged between 12 implantation to recognize rhythms using a meaningful use of speech scale Music group had more exposure to
and 36 months. ranged between 39 keyboard. Parents also played (MUSS); musical stages music at the end of the first year. By
and 96 months. simple melodies repeatedly and questionnaire, open- and the end of the second year music
encouraged their children to listen closed-set speech perception. group developed more than the
and dance with them. control group in all aspects of
/2 years. musical skills.
Petersen et al., 10 NH peers without musical CI /15e18 years. 11 CI adolescents in musical Preattentive and behavioral MMN brain responses for No improvement associated with
(2015) training. training: rhythm, singing, ear discrimination of changes in musical pitch (f0), rhythm, training.
training and computer-based music. Perception of speech in intensity and timbre changes,
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122 117

rhythm of music and speech, attention shift to the expected mo-

CI ¼ cochlear implant; NH ¼ normal hearing; HI ¼ hearing impairment; HA ¼ hearing aid. AB-BA design ¼ all children participated in intervention and control training and served as controls and intervention group. Order of
intervention and control training was counterbalanced across children. LMM ¼ linear mixed modeling. ANOVA ¼ analysis of variance. RM ¼ repeated measures. MMN ¼ mismatch negativity brain response. P3a ¼ positive
response peaking after MMN, reflects attention shift towards sound change salient for the listener. F0 ¼ fundamental frequency; pitch is perceptual correlate of f0. PIQ ¼ performance intelligence quotient (block design) from
CI singers were better in perception
Comfortable singing range, general

patterns) and pitch (f0) perception ments is known to lead to better speech perception at these mo-

effects in perception of speech in

ability to sing (pitch and rhythm

improved in the HI children. No €n and Tillmann, 2015). Based on results

of speech in noise than CI non-

ments (Mattys, 1997; Scho
of Cason et al. (2015), rhythmic priming can improve phonological
production in children with hearing aids and CIs (not included in
the tables). They conducted an experiment where children had to
repeat sentences that were or were not preceded by a rhythmical
prime which either matched or mismatched the meter (i.e., the
chain of stressed syllables) of the sentence. Matching conditions

singers.
resulted in greater phonological accuracy than baseline and mis-
noise.

matching conditions. Plausibly, musical rhythm may have built

expectations which improved both the perception and production
50% correct words in sentences.
discrimination of these, SRT for

Singing Programme (NSP) Sing

specially designed chord pitch

A singing competence profile,

of speech. This process is thought to assist speech perception in

adaptively to obtain the SRT.
SRT for 75% correct words in
discrimination test; Speech

WISC (Wechsler, 2010). SRT ¼ speech reception threshold. MBEMA ¼ a children's version of the MBEA, the Montreal Battery for Evaluation of Musical Abilities (Peretz et al., 2013).
shaped noise was adjusted

€ n, 2012; see also Mattys, 1997; Scho

€n and
illustrated in 4  4 picture
evaluation of the National

sentences in steady noise.

general (Cason and Scho

Up (Welch et al., 2015); a
based on that used in the

sentences, 6 colour and 8

number options. Speech-
perception in noise: In

Sentences/words were

Tillmann, 2015).
Good et al. (2017; Table 3) investigated the effect of musical
training for children with CIs (age 6e15 years). The children were
assigned to individual musical training (including playing piano
and rehearsal of songs vocally) and individual painting lesson
matrix.

groups. Participants could choose the location of training without

knowing the type of training, or they were assigned randomly to
noise. /Mixed-effects ANOVA; t-

musical and painting training groups. The groups did not differ in
Perception of speech in noise.
pitch discrimination, speech

age at testing, age at implantation, CI experience, or speech

Singing competence, chord

perception skills. In line with the correlational and interventional

evidence above (Tables 1e3), musical training was associated with
perception in noise.

improved discrimination of melodic contour and rhythm and

incidental memory for melodies as well as emotional prosody. Art
/RM ANOVA.

training did not lead to the same improvements. Interestingly,

Fuller et al. (2018) conducted a randomised, controlled intervention
/LMM.
tests.

study using adults with CIs. The participants attended 6 weeks at

face-to-face music therapy (training of rhythm perception, musical
small-group interactions (HI pairs).

implantation, also CI children sang

speech perception, music perception, singing, vocal emotion

Emphasis on building a repertoire

/Weekly across two school terms.

of simple songs with actions and
vocal exploration. Also activities
that drew on visual imagery for
sound and that included simple
lessons in large groups (n ¼ 29)
exercises. /6 days (20 h), over 2

12 HI children in weekly music

identification, and music improvisation), computer-based melodic

with NH peers, occasionally in

notation and physical gesture.

Parental singing started from

before the follow-up started.

The same as in Torppa et al.,

contour training or non-musical activities. Improvement of

perception of emotional prosody was found only with face-to-face
music therapy. No improvement in the perception of speech in
quiet or noise was found in this study for any of the groups (Fuller
2014bsee above.

et al., 2018).
Torppa et al. (2014a; Table 3) studied children with CIs (age
weeks.

4e13 years), determining how vocal (synthesized speech) f0, in-

tensity and duration discrimination and prosodic perception
(perception of word and sentence stress) and auditory working
CI and/or HA /5e7

memory developed for 21 children exposed to music (CIm) or not

CI/4e13 years.

(CIn). Measurements were conducted twice, 14e17 months apart.

Children with CIs in the CIm group participated in musical activities
(singing, sensorimotor activities, and music instrument playing),
years.

before and between the measurements (Table 3), most of them

from immediately after implantation. Compared to the CIn chil-
2014bsee above; the same study as
Welch et al., (2015) 17 NH peers in music lessons with

dren, the CIm group took part in significantly more musical activ-
the HI group. They did not have

ities in the home. The CIn children participated in other than

Torppa et al. (2018) The same as in Torppa et al.,

musical hobbies. The musically active CIm group performed as well

as normal-hearing children in stress perception and f0 discrimi-
small-group training.

nation and in auditory working memory (digit span), while the CIn
group performed more poorly. Additionally, only the CIm group
improved with age in word-stress perception and intensity
in Table 1.

discrimination, and over time (during the follow up), in digit span
(for the link of musical training to auditory working memory of
hearing-impaired children, see also Rochette et al., 2014, Table 1).
Hidalgo et al. (2017; Table 3) studied how preceding short-term
rhythmic musical training or speech therapy affected speech
perception for children with CIs and/or hearing aids. The partici-
pating children named pictures presented on a screen, taking turns
with a virtual partner. Alternation rate (fast or slow) and temporal
predictability (match vs mismatch of word stress occurrences) were
.

manipulated. The children with hearing impairment were tested

118 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122

twice, once after 30 min of traditional speech therapy and once after
30 min of individual musical rhythmic training conducted by a
speech therapist. It was found that children with hearing loss
became sensitive to the manipulation of the temporal regularity of
speech stress occurrences only after rhythmic training, when they
could adapt their turns to the speech rhythm (stress patterns) of the
interlocutor. The authors concluded that rhythmic training may help
children with hearing impairment to structure the temporal flow of
their verbal interactions. According to the authors, this could be
indicative of meter (i.e., the regular recurrence of a beat or accents)
perception and/or production being underdeveloped in children
with hearing loss, since normally hearing children were able to do
the task without rhythmic training. It is thus possible that rhythmic
training improves the ability to perceive and understand rhythmical
and metrical structure (Cason et al., 2015). However, musical
training may also have enhanced the encoding of acoustic cues such
as f0, intensity and duration, that characterise stress patterns
(Torppa et al., 2014a), or training could have enhanced auditory
processing in general (Hidalgo et al., 2017).
Vongpaisal et al. (2016; not included in the tables) studied how
children with CIs learned new songs in listening only (auditory
learning), or listening and dancing (auditory-motor learning) con-
ditions. The children could listen or listen and dance to the songs
until they felt they had learned the songs. After the learning phase,
the ability to identify song excerpts, mistuned excerpts (with the
original instruments), and the same songs played with a piano
sound was studied. Compared to listening only, the combination of
listening and dancing led to better identification of songs in ver-
sions that preserved the original instrumental beats and lyrics.
2.4. Summary
For children with hearing impairments, improvements in
musical skills and/or music perception (pitch or rhythm), linked to
perception of speech prosody, have been found with musical ac-
tivities in several studies (in 2/2 correlational, 2/3 intervention
studies without a control group and with statistical analyses, 4/5
intervention studies with a control group; Tables 1e3). There are
also signs of improvement of detection of temporal regularities
(related to perception of stress patterns and speech in general) with
musical activities (Hidalgo et al., 2017; Torppa et al., 2014b, Table 3).
Perception of prosody, which is important for speech perception
and language acquisition (see section 2), improved only with
musical activities in the 3/3 intervention studies with a control
group (emotional prosody: Good et al., 2017, stress perception,
Torppa et al., 2014a; plausibly also in Hidalgo et al., 2017, where the
children served as controls for themselves, Table 3) (for adult CI
users, question-statement prosody, see Lo et al., 2015, section 2.2;
emotional prosody, Fuller et al., 2018, section 2.3). Cortical pro-
cessing of changes in timbre of musical instruments, which is
connected to better perception of speech in noise, showed
improvement with singing in one study only (Torppa et al., 2014b,
2018, Tables 1 and 3; see also improvement of perception of timbre
in adults with CIs, Petersen et al., 2012, section 2.3). And finally,
signs of improvements with musical activities have been found for
perception of phonemes (Rochette et al., 2014, Table 1; see also
Cason et al., 2015, section 2.3; for adult CI users, see Lo et al., 2015,
section 2.2) and speech in noise (Torppa et al., 2018, Table 3),
auditory attention (Torppa et al., 2014b; Table 3), auditory working
memory (Rochette et al., 2014, Table 1; Torppa et al., 2014a, Table 3)
and language skills (Torppa et al., in print), which are important for
learning and educational success.
Even though the results are promising, more evidence is needed.
The number of studies and participants in the studies reviewed is
small, the study designs vary, and even the studies with a control
group are not always well controlled (see Tables 1e3). There is a lot
to improve in the research paradigms, such as assessing speech
perception with a larger battery of tests, and in reporting the
content and practicalities of the intervention in more detail (for
factors affecting the results of musical training, from the perspec-
tive of speech-in-noise perception, see Coffey et al., 2017). Above
all, there is lack of RCTs assessing the effects of musical activities on
language skills of children with hearing impairments.
Children and their families enjoy musical activities. Families
who know about the benefits of music or appreciate music, most
often encourage their children to take part in musical hobbies and
also to make music at home (Driscoll et al., 2015).
According to the studies reviewed above, musical activities may
increase involvement in music, and all studies showing significant
results show improvements of musical skills, music or speech
perception or cognitive aspects with musical activities; none of
them report negative effects. Music may have positive conse-
quences for the lives of children with hearing impairments. From an
ethical point of view, it is not wise to exclude them from musical
activities at home or outside of the home. Therefore, while waiting
for better scientific evidence, we feel that it is important to list
some principles and give our recommendations for the use of music
for children with CIs and/or hearing aids.
3. How to use music to enhance speech and language skills of
hearing-impaired children
It should be understood clearly that traditional speech and
language therapy is of vital importance to hearing-impaired chil-
dren and adolescents. However, musical activities can be used in
the context of speech and language therapy, as an additional
therapy, as a separate hobby, and/or as an activity at home.
We have drafted the following recommendations on the basis of
the intervention studies and correlational studies described above,
and on the basis of the traditional auditory rehabilitation, music
therapy methodologies, and speech and language therapy
methods.

1. Start using music systematically at an early age, before implantation or the application of hearing aids. Continue musical activities more than one year, to improve
speech perception.
For children with hearing impairments, the early start of musical activities, like singing or musical play school, may be beneficial for the perception of prosody and for the
perception of speech in noise, and perhaps for language skills (see the children's ages at the start of musical activities in Torppa et al., 2014a, 2018; vs. null results from
adolescents, Petersen et al., 2015; adults, Fuller et al., 2018). Furthermore, families of children with CIs feel that they and their babies benefit from and enjoy musical
activities starting before implantation (Rocca, 2015), and a hearing-impaired child can benefit from musical activities even before implantation or receiving a hearing aid
due to residual hearing or tactile perception of low frequencies in time synchrony with visual stimulation (multisensory perception, see below). It is also known that the
brain is most plastic at an early age, before 3e4 years (for a review, Sharma et al., 2015), and therefore, musical activities at this age can lead most efficiently to changes in
the brain. However, it may also be good to continue at least one year or longer with musical activities to improve speech perception (see the duration of activities in
Chobert et al., 2014; Slater et al., 2015; Torppa et al., 2018; vs. Fuller et al., 2018; Petersen et al., 2015).
2. Use bodily movements in the rhythm of the music. Use orientations.
The use of music, especially when it involves dance and other sensorimotor activities (used in musical play schools and similar activities, Torppa et al., 2014a), or dancing,
seems to be beneficial for the learning of lyrics (dancing, Vongpaisal et al., 2016) or perception of prosody (Torppa et al., 2014a) by children with CIs. Rhythmic,
 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122 119

(continued )

multisensory stimulation simultaneously with lyrics can improve the perception of speech (for a review, see Torppa et al., 2018). The joy of music that the child can
observe in group music situations can awake the curiosity of the child, and he/she will naturally want to join in (Abdi et al., 2001; Innes-Brown et al., 2013; Koşaner et al.,
2012; Rocca, 2015; for normally-hearing children, Krueger, 2011). For small infants with hearing impairment, holding the baby against the adult's body while singing or
humming, and carrying the baby while walking or dancing to the rhythm of the music are good methods for stimulating the audio-tactile-vestibular system (Phillips-
Silver and Trainor, 2005), and for keeping the child near enough to hear the lyrics well (the closer the distance between the singer and the child is, the louder is the sound
is for the child).
Use consistent, large body movements that are rhythmically co-occurring with the music. Let your body movements reflect the style of the music: fast or slow, happy or sad,
aggressive or melancholic, to aid learning of the rhythm and beat of music (see for example Rocca, 2015), which are both plausibly important for the perception of speech
(section 2.3). Repeat the same bodily movements with the same piece of music consistently. Repetition is highly important for the auditory learning of children with
hearing impairments (Estabrooks, 1994; Hull, 2013).
Help the child locate musical sounds in space: point with your finger and anchor your gaze to the direction of the sound. You can make this into a game: where is the sound
coming from? This gives the child the opportunity to learn to recognize sounds and to practice sound localization, and therefore these are common activities in speech and
language therapy for hearing-impaired children (Estabrooks, 1994). Multisensory integration at the neural level is vital for making sense of multisensory information like
speech, which contains both visual and auditory stimulation, and this has been extensively studied (Calvert et al., 1998; King and Calvert, 2001; Shimojo and Shams,
2001).
Be consistent with your movements with respect to the sound parameters. In all musical play with hearing-impaired children, sounds high in f0 should be connected with
high hand movements, and sounds low in f0 should be connected with low hand movements or movements of the feet. Move your hand or a toy up and down with the f0
of the music (Rocca, 2012). These exercises give an opportunity for multisensory, audio-visual learning of changes in f0. Especially early-implanted children may be good
multisensory integrators (Schorr et al., 2005), and may benefit from visual cues. Hand movements which visualize f0 are also used in musical training for normal-hearing
children (for example, Kodaly, https://en.wikipedia.org/wiki/Kod%C3%A1ly_method).
3. Use singing as your main instrument, especially with a young child.
All studies of hearing-impaired children showing improvement of speech perception (prosody, phonemic discrimination, speech in noise) associated with musical ac-
tivities have included singing, face-to-face with children (see Tables 1 and 3, and the review above; see also Fuller et al., 2018, for adults with CIs). There are several
reasons why singing can be more efficient for speech perception than musical instrument playing (for an overview, Torppa et al., 2018).
Make sure that the hearing-impaired children can see your lips moving when you sing. This helps their brains connect the auditory information to lip and tongue movements
(multisensory perception, Schorr et al., 2005). Especially vowels are accompanied by changes in the spectral content of speech stimulus (Stevens, 1998), and seeing lip and
tongue movements can lead to better perception of spectral details and better perception of speech in quiet or noise (for an overview, see Torppa et al., 2018). This is most
natural at an early age, with parents. It is also important to keep in mind that it is easiest for the hearing-impaired auditory system to make sense of music when one
instrument, especially singing, is presented without accompaniment (for the difficulties in perception of simultaneous musical sounds by hearing-impaired individuals,
see Galvin et al., 2009; Looi et al., 2008).
4. Engage children in musical activities in small groups; use several musical instruments and pictures/toys presenting lyrics.
Ensure that the group size is small enough (plausibly up to 6 children) to avoid excessive noise and to keep the interest of the child on the lips and voice of the group leader
or the other group members and in making music. For hearing-impaired children, large group sizes are associated with null-results on speech-in-noise perception (Welch
et al., 2015), while studies suggesting improvement of perception of prosody or other aspects of speech perception with musical activities used individual lessons (Good
et al., 2017), individual singing at home (Torppa et al., 2018) or groups of 5e6 children (Rochette et al., 2014).
Use small, colourful, interesting instruments like rhythmic instruments, xylophones, and small stringed instruments to let the children become curious about musical
sounds. Let the children be active and try out different types of musical instruments. Playing an instrument by oneself is a highly multisensory activity which can lead to
better perception of f0, timbre, or rhythm, linked to perception of prosody or speech in noise (Schorr et al., 2005; Torppa et al., 2014a, 2018), and may be more effective
than listening only (Lappe et al., 2008). Playing staccato or legato can also improve the perception of intensity envelopes (Patel, 2011), which are also important for
perception of speech (Chobert et al., 2014). Since the perception of lyrics is challenging when children or group leaders play instruments together with singing (see Galvin
et al., 2009; Looi et al., 2008, above), use pictures visualizing lyrics, especially at the first stage of learning of lyrics of songs.
5. Use plenty of repetition.
Sing and play the same songs over and over again. Repetition is very helpful for auditory memory and it allows the auditory system to form models of the song and, over
the course of the repetitions, make the model more and more precise (Estabrooks, 1994; Hull, 2013). Using the same song always at the beginning and at the end of the
music session will help the child orientate and grasp the structure of the music and the session better e a method that is traditionally used in musical play schools and in
music therapy.
6. Use plenty of turn-taking.
Use songs which include turn-taking: The child will be given an opportunity for auditory closure (to continue the song when the adult stops singing, as used in the Hanen
program and AVT, Estabrooks, 1994), or the adult will sing a very short section first and then it is the child's turn to repeat it. Using short sections is important, since
children with hearing impairments have difficulties with auditory working memory (for an overview, see Torppa et al., 2014a), and, thus, in memorizing long sections.
Moreover, turn-taking allows the child to listen, to produce speech sounds, and to compare the adult's and his/her own speech production, including phoneme quality and
prosodic features. This is important since repeating lyrics with slow tempo, which is typical for music (Patel, 2014), may facilitate the learning of phonological codes for
words (for an overview, see Torppa et al., 2018).
7. Give advice to families on how to use music with their child.
Involve families in music-making with their child. Use videos and teaching materials to help the parents understand how integral and easy music-making can be in
everyday life. Teach songs to the parents and help them engage their own child into the world of music in their own home. This can increase the amount of singing and
other musical activities at home, which can further lead to improvements in the perception of prosody, in attention functions, and further, in the perception of speech in
noise and in language skills (see the review above; Torppa et al., 2014a,b; Torppa et al., 2018; Torppa et al., in print). Help parents if they encounter problems with music
schools or academies, to help children to continue musical activities long enough to improve speech perception and language skills (see suggestion 1 above).
If the hearing-impaired child has siblings, involve them in the musical activities, as well as the parents of the child. The siblings, when engaged in musical activities, will
continue singing and playing music at home, with plenty of repetition of music and a model for music making, thus creating a good environment for their hearing-
impaired sibling (Driscoll et al., 2015; for the role of repetition, see above).
8. Use computer games and apps to help the child perceive and produce sounds.
Give the hearing-impaired child, his/her parents, and teachers lists of apps and computer games that are available for practicing sound perception and production. Advise
the child and his/her parents on how to use the software. (For the possible benefits of computer-based melodic contour training for adult CI recipients, for perception of
prosody and consonants: see Lo et al., 2015; for perception of melodic contours, see Fuller et al., 2018; for perception of melodic contours for children with CIs, see Fu
et al., 2015, Table 2).
9. Give advice to school music teachers.
The hearing-impaired child has the right to take part in daycare and school music lessons, and to obtain a positive and encouraging image of his/herself as a music maker.
To achieve this, not only inform speech and language therapists, professionals at daycares and school teachers, including music teachers, about the results and suggestions
in this review, but also give advice to them about the effects of the hearing impairment on music perception of the child. For example, the teacher should know that a child
with a CI has good possibilities for learning rhythm (for an overview, Gfeller, 2016), but should not be asked to sing alone in front of other children. Poor perception of
pitch (see section 1.2, and Gfeller, 2016) make it difficult to sing in tune. Thus, singing in front of normally hearing peers can lead to unpleasant feeling or even bullying.
However, it is also important to keep in mind that pitch-based training can improve the perception of pitch and together with this, speech perception (see section 2.4 and
Tables 1e3). To motivate adolescents, a good solution for school music lessons is a band practice room where the hearing-impaired child can be part of a pop/rock band
playing drums and percussion. Such activities are often very much appreciated by children and teenagers and provide a good basis for healthy, positive self-esteem as a
(continued on next page)
120 R. Torppa, M. Huotilainen / Hearing Research 380 (2019) 108e122
(continued )
music maker, as noted in the Resonaari music camps of the association for children with CIs and their families in Finland (LapCI ry), in Mary Hare School (Rocca, 2012), and
for normally-hearing teenagers (Saarikallio, 2011).
10. Support musical hobbies of teenagers with hearing impairments.
There are several ways that children and teenagers with hearing impairments can have musical hobbies. In music schools, an individual study plan is needed. The United
Nation's Declaration of the Rights of the Child states that all children have the right to culture, which includes music (Ruisma €ki and Ruokonen, 2009). A hearing
impairment should not prevent the child from taking part in musical hobbies. Musical schools and academies need to realize this right and make it practically possible for
all children and adolescents to take part in their teaching. Foundations and other sources that lend musical instruments to students should specifically consider hearing-
impaired students.
With this list of advice and recommendations, we believe that
hearing-impaired children, their parents, siblings, other family
members, teachers, speech therapists and other people close to
them can enhance the environment with music, making it possible
for these children to benefit from musical activities in respect to
speech perception and learning, thus supporting these children and
adolescents to reach their abilities as full members of the society
and in actively contributing as citizens.
Contributions
The two authors have equally contributed to the initial idea of
the review, to the drafting the first version and revision of the
manuscript, and R. T. finalized it.
Declaration of interest
None.
Funding
This work was supported by the Signe and Ane Gyllenberg
Foundation (the grant for the first author, Ritva Torppa).
Acknowledgements
We thank the reviewers and especially Brian Moore for helpful
comments.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.heares.2019.06.003.
Torppa et al.,
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